NASAL SPRAY ALLERGY 24HR APO-TRIAMCINOLONE AQ

Transcription

1 PRODUCT MONOGRAPH NASAL SPRAY ALLERGY 24HR Adults and Children 12 Years and Older APO-TRIAMCINOLONE AQ Children 4 to 12 Years Triamcinolone Acetonide Aqueous Nasal Spray 55 mcg/metered Spray Apotex Standard CORTICOSTEROID FOR NASAL USE APOTEX INC. DATE OF REVISION: 150 Signet Drive January 29, 2016 Toronto Ontario M9L 1T9 Control No: Page 1 of 33

2 Table of Contents PART I: HEALTH PROFESSIONAL INFORMATION... 3 SUMMARY PRODUCT INFORMATION... 3 INDICATIONS AND CLINICAL USE... 3 CONTRAINDICATIONS... 4 WARNINGS AND PRECAUTIONS... 4 ADVERSE REACTIONS... 6 DOSAGE AND ADMINISTRATION...10 OVERDOSAGE...11 ACTION AND CLINICAL PHARMACOLOGY...12 STORAGE AND STABILITY...13 DOSAGE FORMS, COMPOSITION AND PACKAGING...13 PART II: SCIENTIFIC INFORMATION...15 PHARMACEUTICAL INFORMATION...15 CLINICAL TRIALS...16 DETAILED PHARMACOLOGY...18 TOXICOLOGY...19 REFERENCES...21 PART III: CONSUMER INFORMATION (NASAL SPRAY ALLERGY 24HR)...22 PART III: CONSUMER INFORMATION (APO-TRIAMCINOLONE AQ)...28 Page 2 of 33

3 NASAL SPRAY ALLERGY 24HR Adults and Children 12 and Older APO-TRIAMCINOLONE AQ Children 4 to 12 Years Triamcinolone Acetonide Aqueous Nasal Spray 55 mcg/metered Spray Apotex Standard PART I: HEALTH PROFESSIONAL INFORMATION SUMMARY PRODUCT INFORMATION Route of Administration Nasal Dosage Form / Strength Aqueous Nasal Spray 55 mcg/metered Spray All Nonmedicinal Ingredients Benzalkonium chloride, dextrose monohydrate, edetate disodium dihydrate, hydrochloric acid, microcrystalline cellulose and carboxymethylcellulose sodium, polysorbate 80, purified water and sodium hydroxide (ph adjuster) INDICATIONS AND CLINICAL USE Adults and children 12 years of age and older: NASAL SPRAY ALLERGY 24HR (triamcinolone acetonide aqueous nasal spray) is indicated for the temporary relief of multi-symptoms of perennial and seasonal allergic rhinitis such as: nasal congestion runny nose sneezing itchy nose NASAL SPRAY ALLERGY 24HR is available without a prescription for adults and children older than 12 years. Children 4 to 12 years of age: APO-TRIAMCINOLONE AQ (triamcinolone acetonide aqueous nasal spray) is indicated for the topical treatment of the symptoms of perennial and seasonal allergic rhinitis unresponsive to conventional treatment. APO-TRIAMCINOLONE AQ is available only by prescription for children 4 to 12 years of age. Regular usage is essential since maximum relief may not be obtained until after 2 to 3 days of treatment. Page 3 of 33

4 CONTRAINDICATIONS Hypersensitivity to any of the ingredients of NASAL SPRAY ALLERGY 24HR / APO- TRIAMCINOLONE AQ, and in patients with active or quiescent tuberculosis, or untreated fungal, bacterial and viral infection. WARNINGS AND PRECAUTIONS General The replacement of a systemic steroid with NASAL SPRAY ALLERGY 24HR / APO- TRIAMCINOLONE AQ has to be gradual and carefully supervised by the physician. The guidelines under "Dosage and Administration" should be followed in all such cases. Patients should be informed that the full effect of NASAL SPRAY ALLERGY 24HR / APO- TRIAMCINOLONE AQ therapy is not achieved until 2 to 3 days of treatment have been completed. Treatment of seasonal rhinitis should, if possible, start before the exposure to allergens. Patients should be advised to inform subsequent physicians of prior use of corticosteroids. To ensure the proper dosage and administration of the drug, the patient should be instructed to read the consumer package insert (see NASAL SPRAY ALLERGY 24HR / APO- TRIAMCINOLONE AQ (see Part III: CONSUMER INFORMATION section). Dependence/Tolerance Treatment with NASAL SPRAY ALLERGY 24HR / APO-TRIAMCINOLONE AQ should not be stopped abruptly but tapered off gradually. In patients previously on prolonged periods or high doses of systemic steroids, the replacement with a topical corticosteroid can be accompanied by symptoms of withdrawal, e.g. joint and/or muscular pain, lassitude, and depression; in severe cases, adrenal insufficiency may occur, necessitating the temporary resumption of systemic steroid therapy. These patients should be carefully monitored for acute adrenal insufficiency in response to stress. Careful attention must be given to patients with asthma or other clinical conditions in whom a rapid decrease in systemic steroids may cause a severe exacerbation of their symptoms. Ear/Nose/Throat Because of the inhibitory effect of corticosteroids on wound healing, in patients who have had recent nasal surgery or trauma, a nasal corticosteroid should be used with caution until healing has occurred. As with other nasally inhaled corticosteroids, nasal septal perforations have been reported in rare instances. The possibility of atrophic rhinitis and/or pharyngeal candidiasis should be kept in mind. In clinical studies with triamcinolone acetonide aqueous nasal spray, the development of localized infections of the nose and pharynx with Candida albicans has rarely occurred. When such an infection develops it may require treatment with appropriate local or systemic therapy and temporary discontinuation of treatment with NASAL SPRAY ALLERGY 24HR / APO- TRIAMCINOLONE AQ. Therefore, patients using NASAL SPRAY ALLERGY 24HR / APO- TRIAMCINOLONE AQ over several months or longer should be examined periodically for evidence of Candida infection or other signs of adverse effects on the nasal mucosa. Page 4 of 33

5 Endocrine and Metabolism No apparent evidence of hypothalamic-pituitary-adrenal (HPA) axis suppression was observed in clinical studies following treatment with triamcinolone acetonide aqueous nasal spray at recommended doses. When intranasal steroids are used at higher than recommended dosages or in susceptible individuals at recommended dosages, systemic corticosteroid effects may occur, such as hypercorticism, suppression of HPA function and/or reduction of growth velocity in children or teenagers. Children should be maintained on the lowest dose which delivers adequate symptom control (see DOSAGE AND ADMINISTRATION section). A one-year double-blind, placebo-controlled parallel group study in 298 treated pediatric patients (3 to 9 years of age) was conducted to assess the effect of triamcinolone acetonide aqueous nasal spray (once-daily dose of 110 microgram) on growth velocity using stadiometry. From the primary analysis of evaluable patients (134 triamcinolone acetonide aqueous nasal spray and 133 placebo), the estimated growth velocity in the triamcinolone acetonide aqueous nasal spray group was 0.45 cm/year lower than that in the placebo group with 95% CI ranging between 0.11 to 0.78 cm/year lower than placebo. The clinical long-term relevance of this change in growth velocity associated with nasal corticosteroids is not known. Physicians should closely follow the growth of children and adolescents taking corticosteroids, by any route, and weigh the benefits of corticosteroid therapy against the possibility of growth suppression. Therapy should be managed with the aim of reducing the dose of nasal corticosteroid if possible, to the lowest dose at which effective control of symptoms is maintained. Osteoporosis is a possible adverse effect associated with a long-term use of large doses of corticosteroids. Immune Corticosteroids may mask some signs of infection and new infections may appear. A decreased resistance to localized infections has been observed during corticosteroid therapy; this may require treatment with appropriate therapy or stopping the administration of NASAL SPRAY ALLERGY 24HR / APO-TRIAMCINOLONE AQ. Patients who are on immunosuppressant drugs are more susceptible to infections than healthy individuals. Chickenpox and measles, for example, can have a more serious or even fatal course in children or adults on immunosuppressant doses of corticosteroids. In such children, or in adults who have not had these diseases, particular care should be taken to avoid exposure. If exposed, therapy with varicella zoster immune globulin (VZIG) or pooled intravenous immunoglobulin (IVIG), as appropriate, may be indicated. If chickenpox develops, treatment with antiviral agents may be considered. Ophthalmologic Glaucoma and/or cataracts have been reported in patients receiving nasal corticosteroids. Therefore, close monitoring is warranted in patients with a change in vision or with a history of increased intraocular pressure, glaucoma, and/or cataracts. Sensitivity/Resistance There is an enhanced effect of corticosteroids on patients with hypothyroidism and in those with cirrhosis. Acetylsalicylic acid should be used cautiously in conjunction with corticosteroids in hypothrombinemia. Page 5 of 33

6 The use of NASAL SPRAY ALLERGY 24HR / APO-TRIAMCINOLONE AQ with alternate day systemic prednisone could increase the likelihood of HPA suppression compared to a therapeutic dose of either one alone. Therefore, NASAL SPRAY ALLERGY 24HR / APO-TRIAMCINOLONE AQ should be used with caution in patients already receiving alternate-day prednisone treatment for any disease. Special Populations Pregnant Women The safety of triamcinolone acetonide aqueous nasal spray in pregnancy has not been established. If used, the expected benefits should be weighed against the potential hazard to the fetus, particularly during the first trimester of pregnancy. Like other glucocorticosteroids, triamcinolone acetonide is teratogenic to rodents and non-human primates (see TOXICOLOGY section). The relevance of these findings to humans has not yet been established. Infants born of mothers who have received substantial doses of glucocorticosteroids during pregnancy should be carefully observed for hypoadrenalism. Nursing Women Glucocorticosteroids are excreted in human milk. It is not known whether triamcinolone acetonide would be secreted in human milk, but it is suspected to be likely. The use of NASAL SPRAY ALLERGY 24HR / APO-TRIAMCINOLONE AQ in nursing mothers requires that the possible benefits of the drug be weighed against the potential hazards to the infant. Pediatrics NASAL SPRAY ALLERGY 24HR / APO-TRIAMCINOLONE AQ is not presently recommended for children younger than 4 years of age due to limited clinical data in this age group. Oral corticosteroids have been shown to cause growth suppression in children and teenagers, particularly with higher doses over extended periods. If a child or teenager on any corticosteroids appears to have growth suppression, the possibility that they are particularly sensitive to this effect of steroids should be considered. Monitoring and Laboratory Tests During long-term therapy, pituitary-adrenal function and hematological status should be assessed. ADVERSE REACTIONS Adverse Drug Reaction Overview Systemic and local corticosteroid use may result in the following: Epistaxis, ulcerations, Candida albicans infection, nasal septal perforation, impaired wound healing (see WARNINGS AND PRECAUTIONS section) Glaucoma and Cataracts (see WARNINGS AND PRECAUTIONS section) Immunosuppression (see WARNINGS AND PRECAUTIONS section) Hypothalamic-pituitary-adrenal (HPA) axis effects, including reduction of growth velocity (see WARNINGS AND PRECAUTIONS section) Page 6 of 33

7 Clinical Trial Adverse Drug Reactions Because clinical trials are conducted under very specific conditions, the adverse reaction rates observed in the clinical trials may not reflect the rates observed in practice and should not be compared to the rates in the clinical trials of another drug. Adverse drug reaction information from clinical trials is useful for identifying drug-related adverse events and for approximating rates. In placebo-controlled, double-blind and open-label clinical studies, 1483 adults and children 12 years and older received treatment with triamcinolone acetonide aqueous nasal spray. These patients were treated for an average duration of 50.7 days. In the controlled, seasonal trials (2-5 weeks duration) from which the following adverse reaction data is derived, 1394 patients were treated with triamcinolone acetonide aqueous nasal spray for an average of 18.7 days. In the longterm, open-label study, the 172 patients enrolled received treatment for an average of 286 days duration. The most commonly reported adverse reactions included those involving mucous membranes of the nose and throat. The three most prevalent adverse reactions considered to be at least possibly drug-related in adults and children 12 years and older were rhinitis (1.5%), headache (0.7%), and pharyngitis (0.3%), and in children 4 to 12 years were epistaxis (3.1%), rhinitis (1.4%) and headache (1.2%). Children 4 to 12 years of age (n= 622) were studied in 3 controlled clinical trials. Of these, 179 received 110 mcg/day and 215 received 220 mcg/day of triamcinolone acetonide aqueous nasal spray in two, six, or twelve week trials. The longest average duration of treatment for patients receiving 110 mcg/day was 76.3 days and 79.6 days for those receiving 220 mcg/day. The incidence of specific nasopharyngeal-related adverse reactions considered drug related is summarized as follows: Table 1: Nasopharyngeal Adverse Reactions Nasal AEs (overall) Placebo (N=176) Triamcinolone Acetonide Aqueous Nasal Spray 110 mcg (N=179) Triamcinolone Acetonide Aqueous Nasal Spray 220 mcg (N=187) Placebo (N=626) Triamcinolone Acetonide Aqueous Nasal Spray mcg (N=1068) 15 (8.5%) 8 (4.5%) 12 (6.4%) 20 (3.2%) 31 (2.9%) Dry mucous (0.3%) 3 (0.3%) membranes Epistaxis 9 (5.1%) 6 (3.4%) 6 (3.2%) 3 (0.5%) 17 (1.6%) Nasal irritation 5 (2.8%) 0 2 (1.1%) 3 (0.5%) 9 (0.8%) Naso-sinus congestion 0 1 (0.6%) 1 (0.5%) 1 (0.2%) 2 (0.2%) Sneezing 1 (0.6%) 0 2 (1.1%) 6 (1.0%) 2 (0.2%) Throat discomfort 1 (0.6%) 1 (0.6%) 1 (0.5%) 6 (1.0%) 3 (0.3%) Page 7 of 33

8 These adverse reactions, with the exception of epistaxis (in adults), and the exception of nasal congestion and sneezing (in children) were reported at approximately the same or lower incidence as placebo treated patients. Only 1% of the patients in the controlled trials discontinued treatment (e.g. pharyngitis, headache). In children, no patient receiving 110 mcg/day discontinued due to a serious adverse event and one patient receiving 220 mcg/day discontinued due to a serious event that was considered not drug related. Overall, these studies found the adverse experience profile for triamcinolone acetonide aqueous nasal spray to be similar to placebo. The following tables summarize the adverse events (% of patients) present in at least 5% of patients in the double-blind and open label phase studies in adults and in controlled studies in children 4 to 12 years of age. Table 2: Adverse Events in Adults STUDIES IN ADULTS VARIABLES Double-Blind Open Label Triamcinolone Placebo N=90 Triamcinolone Acetonide Aqueous Nasal Spray 220 mcg N=88 Acetonide Aqueous Nasal Spray 220/110 mcg N=172 Flu Syndrome 5 (5.6%) 5 (5.7%) 17 (9.9%) Headache 12 (13.3%) 6 (6.8%) 38 (22.1%) Epistaxis 1 (1.1%) 6 (6.8%) 31 (18.0%) Pharyngitis 5 (5.6%) 13 (14.8%) 55 (32.0%) Rhinitis 5 (5.6%) 6 (6.8%) 49 (28.5%) Injury Accident (11.6%) Back Pain (7.6%) Cough Increased (8.1%) Sinusitis (15.7%) Pain (5.8%) Diarrhea (5.8%) Page 8 of 33

9 Table 3: Adverse Events in Children Placebo N=202 STUDIES IN CHILDREN 4-12 YEARS OF AGE Triamcinolone Acetonide Aqueous Nasal Spray 110 mcg N=179 Triamcinolone Acetonide Aqueous Nasal Spray 220 mcg N=215 Triamcinolone Acetonide Aqueous Nasal Spray 440 mcg N=26 Fever 11 (5.4%) 8 (4.5%) 12 (5.6%) 2 (7.7%) Flu syndrome 15 (7.4%) 16 (8.9%) 4 (1.9%) 0 Headache 22 (10.9%) 18 (10.1%) 16 (7.4%) 4 (15.4%) Infection 15 (7.4%) 13 (7.3%) 16 (7.4%) 0 Injury accidental 3 (1.5%) 3 (1.7%) 4 (1.9%) 2 (7.7%) Cough increased 13 (6.4%) 15 (8.4%) 15 (7.0%) 0 Epistaxis 14 (6.9%) 8 (4.5%) 10 (4.7%) 1 (3.8%) Pharyngitis 13 (6.4%) 14 (7.8%) 16 (7.4%) 2 (7.7%) Rhinitis 18 (8.9%) 18 (10.1%) 18 (8.4%) 0 Sinusitis 16 (6.4%) 7 (3.9%) 7 (3.3%) 0 In addition, the most frequent (frequencies 2%) adverse reactions in adults and children greater than 6 years are: Headache, epistaxis, cough, bronchitis, dyspepsia, rhinitis, pharyngitis, flu syndrome, and tooth disorder. Additional adverse reactions in pediatric patients: Reduction of growth velocity (see WARNINGS AND PRECAUTIONS Endocrine and Metabolism section) In patients aged 2 to 5 years, the following adverse reactions have been observed (frequency 2%): Headache, pharyngolaryngeal pain, nasopharyngitis, excoriation, diarrhea, and upper abdominal pain. In the event of accidental overdose, an increased potential for these adverse experiences may be expected, but systemic adverse experiences are unlikely (see OVERDOSAGE section). Hypersensitivity reactions including skin rash and edema of the face or tongue have been reported with other intranasal corticosteroids. When patients are transferred to NASAL SPRAY ALLERGY 24HR / APO-TRIAMCINOLONE AQ from a systemic steroid, allergic conditions such as asthma or eczema may be unmasked (see WARNINGS AND PRECAUTIONS section). Page 9 of 33

10 Post-Marketing Adverse Drug Reactions The following additional adverse reactions have been reported during post-marketing experience; they are derived from spontaneous reports and therefore, the frequency of these adverse reactions is not known: nasal irritation, dry mucous membrane, nasal congestion, sneezing alterations of taste and smell, nausea, insomnia, dizziness, fatigue, dyspnea, decreased blood cortisol, cataract, glaucoma, increased ocular pressure, pruritus, rash, and hypersensitivity. As with other nasally inhaled corticosteroids, nasal septum perforations have been reported in rare instances. DOSAGE AND ADMINISTRATION Dosing Considerations See WARNINGS AND PRECAUTIONS section. NASAL SPRAY ALLERGY 24HR is available without a prescription for adults and children 12 years of age and older. APO-TRIAMCINOLONE AQ is available only by prescription for children between the ages of 4 and 12 years. APO-TRIAMCINOLONE AQ is not recommended for children under 4 years of age. Careful attention must be given to patients previously treated for prolonged periods with systemic corticosteroids when transferred to NASAL SPRAY ALLERGY 24HR / APO-TRIAMCINOLONE AQ. Initially, NASAL SPRAY ALLERGY 24HR / APO-TRIAMCINOLONE AQ and the systemic corticosteroid must be given concomitantly, while the dose of the latter is gradually decreased. The usual rate of withdrawal of the systemic steroid is the equivalent of 2.5 mg of prednisone every four days if the patient is under close supervision. If continuous supervision is not feasible, the withdrawal of the systemic steroid should be slower, approximately 2.5 mg of prednisone (or equivalent) every ten days. If withdrawal symptoms appear, the previous dose of the systemic steroid should be resumed for a week before further decrease is attempted. Recommended Dose and Dosage Adjustment Adults and children 12 years of age and older: The recommended starting dose of NASAL SPRAY ALLERGY 24HR is 220 mcg as two sprays in each nostril once daily. It is always desirable to titrate an individual patient to the minimum effective dose to reduce the possibility of side effects. Therefore, when the maximum benefit has been achieved and symptoms have been controlled, reducing the dose to 110 mcg (one spray in each nostril once daily) has been shown to be effective in maintaining control of the allergic rhinitis symptoms in patients who were initially controlled at 220 mcg/day (see WARNINGS AND PRECAUTIONS, ADVERSE REACTIONS & NASAL SPRAY ALLERGY 24HR PART III: CONSUMER INFORMATION sections). Children 4 to 12 years of age: APO-TRIAMCINOLONE AQ is available only by prescription for children between the ages of 4 and 12 years. The recommended starting dose is 110 mcg per day given as one spray in each nostril once daily. Patients who do not achieve maximum symptom control may benefit from a dose of 220 mcg given as 2 sprays in each nostril once daily. Once symptoms are controlled, patients should be maintained on 110 mcg (1 spray in each nostril) once daily. Page 10 of 33

11 Administration The therapeutic effects of corticosteroids, unlike those of decongestants, are not immediate. Since the effect of NASAL SPRAY ALLERGY 24HR / APO-TRIAMCINOLONE AQ depends on its regular use, patients must be instructed to take the nasal inhalations at regular intervals and not as with other decongestant nasal sprays, as they feel necessary. In the presence of excessive nasal mucus secretion or edema of the nasal mucosa, the drug may fail to reach the site of action. In such cases it is advisable to use a nasal vasoconstrictor for two to three days prior to NASAL SPRAY ALLERGY 24HR / APO-TRIAMCINOLONE AQ therapy. Patients should be instructed on the correct method of use, which is to blow the nose, then insert the nozzle firmly into the nostril, compress the opposite nostril and actuate the spray while inspiring through the nose, with the mouth closed. Adults and children 12 years of age and older: An improvement of symptoms usually becomes apparent within a few days after the start of therapy. NASAL SPRAY ALLERGY 24HR should not be continued beyond one week in the absence of significant symptomatic improvement. Children 4 to 12 years of age: An improvement of symptoms usually becomes apparent within a few days after the start of therapy. However symptomatic relief may not occur in some patients for as long as two weeks. APO-TRIAMCINOLONE AQ should not be continued beyond three weeks in the absence of significant symptomatic improvement. OVERDOSAGE For management of a suspected overdose, contact the regional Poison Control Centre. Like any other nasally administered corticosteroid, acute overdosing is unlikely in view of the total amount of active ingredient present. In the event that the entire contents of the bottle were administered all at once, via either oral or nasal application, clinically significant systemic adverse events would most likely not result. The patient may experience some gastrointestinal upset if taken orally. However when used chronically in excessive doses or in conjunction with other corticosteroid formulations, systemic corticosteroid effects such as hypercorticism and adrenal suppression may appear. If such changes occur, the dosage of NASAL SPRAY ALLERGY 24HR / APO- TRIAMCINOLONE AQ should be discontinued slowly consistent with accepted procedures for discontinuation of chronic steroid therapy. (See DOSAGE AND ADMINISTRATION section) The restoration of hypothalamic-pituitary axis may be slow; during periods of pronounced physical stress (i.e. severe infections, trauma, surgery) a supplement with systemic steroids may be advisable. Page 11 of 33

12 ACTION AND CLINICAL PHARMACOLOGY Mechanism of Action Triamcinolone acetonide is a potent anti-inflammatory steroid with strong topical and weak systemic activity. Triamcinolone acetonide is a more potent derivative of triamcinolone. Although triamcinolone itself is approximately one to two times as potent as prednisone in animal models of inflammation, triamcinolone acetonide is approximately 8 times more potent than prednisone. When administered intranasally in therapeutic doses, it has a direct anti-inflammatory action on the nasal mucosa, the mechanism of which is not yet completely defined. The minute amount absorbed in therapeutic doses has not been shown to exert any apparent clinical systemic effects. Corticosteroids are very effective. However, when allergic symptoms are very severe, local treatment with recommended doses (microgram) of any available topical corticosteroid are not as effective as treatment with larger doses (milligram) of oral or parenteral formulations. Corticosteroids do not have an immediate effect on allergic signs and symptoms. Adults and children 12 years of age and older: An improvement of symptoms may be seen as early as the first day after initiation of treatment and full benefit may be expected in 3 to 4 days. NASAL SPRAY ALLERGY 24HR should not be continued beyond one week in the absence of significant symptomatic improvement. Children 4 to 12 years of age: An improvement of symptoms may be seen as early as the first day after initiation of treatment and full benefit may be expected in 3 to 4 days. However, symptomatic relief may not occur in some patients for as long as two weeks. APO-TRIAMCINOLONE AQ should not be continued beyond three weeks in the absence of significant symptomatic improvement. Pharmacokinetics Based upon intravenous dosing of triamcinolone acetonide phosphate ester, the half-life of triamcinolone acetonide was reported to be 88 minutes. The volume of distribution (Vd) reported was 99.5 L (SD ± 27.5) and clearance was 45.2 L/hour (SD ± 9.1) for triamcinolone acetonide. The plasma half-life of corticosteroids does not correlate well with the biologic half-life. Pharmacokinetic characterization of the triamcinolone acetonide aqueous nasal spray formulation was determined in both normal adult subjects and patients with allergic rhinitis. Single dose intranasal administration of 220 mcg of triamcinolone acetonide aqueous nasal spray in normal adult subjects and patients demonstrated minimal absorption of triamcinolone acetonide. The mean peak plasma concentration was approximately 0.5 ng/ml (range: 0.1 to 1.0 ng/ml) and occurred at 1.5 hours post dose. The mean plasma drug concentration was less than 0.06 ng/ml at 12 hours, and below the assay detection limit at 24 hours. The average terminal half-life was 3.1 hours. Dose proportionality was demonstrated in normal subjects and in patients following a single intranasal dose of 110 mcg or 220 mcg triamcinolone acetonide aqueous nasal spray. Triamcinolone acetonide aqueous administered intranasally has been shown to be minimally absorbed into the systemic circulation in humans. Patients with active rhinitis showed absorption similar to that found in normal volunteers. Page 12 of 33

13 In order to determine if systemic absorption plays a role in triamcinolone acetonide aqueous nasal spray treatment of allergic rhinitis symptoms, a two week double-blind placebo-controlled clinical study was conducted comparing triamcinolone acetonide aqueous nasal spray, orally ingested triamcinolone acetonide, and placebo in 297 patients with seasonal allergic rhinitis. The study demonstrated that the therapeutic efficacy of triamcinolone acetonide aqueous nasal spray can be attributed to the topical effects of triamcinolone acetonide. Special Populations and Conditions Pediatrics: Following multiple doses in pediatric patients ages 6 to 12 years old receiving 440 mcg/day, plasma drug concentration, AUC, C max and T max were similar to those values observed in adult patients. Other Studies HPA Axis Suppression: In order to evaluate the effects of systemic absorption on the Hypothalmic-Pituitary-Adrenal (HPA) axis, a clinical study was performed comparing 220 mcg or 440 mcg triamcinolone acetonide aqueous nasal spray, or 10 mg prednisone to placebo for 42 days. Adrenal response to a 6-hour cosyntropin stimulation test clearly indicated that triamcinolone acetonide aqueous nasal spray administered at doses of 220 mcg and 440 mcg had no effect on HPA activity versus placebo. Conversely, oral prednisone at 10 mg/day significantly reduced the response to ACTH. A six week study was conducted in 80 pediatric patients to evaluate the effect of 220 mcg or 440 mcg of triamcinolone acetonide aqueous nasal spray versus placebo on HPA function. No evidence of adrenal axis suppression was observed in the pediatric patients exposed to systemic levels of triamcinolone acetonide higher than the systemic levels observed following administration of the maximum recommended dose of triamcinolone acetonide aqueous nasal spray. In a 6-week randomized, double-blind, placebo-controlled clinical study evaluating the effect of triamcinolone acetonide aqueous nasal spray (once-daily dose of 110 micrograms or 220 micrograms) on HPA axis function (as measured by 24-hour serum cortisol AUC) in 140 children (2 to 11 years of age), no statistically significant difference from placebo was observed. The ratio of triamcinolone acetonide aqueous nasal spray to placebo was 0.966, 95% CI (0.892, 1.045). STORAGE AND STABILITY Store at room temperature 15C to 30C. DOSAGE FORMS, COMPOSITION AND PACKAGING Composition NASAL SPRAY ALLERGY 24HR / APO-TRIAMCINOLONE AQ is an unscented, thixotrophic, water-based metered-dose pump spray formulation unit containing a microcrystalline suspension of triamcinolone acetonide (9.075 mg triamcinolone acetonide / bottle) in an aqueous medium. Page 13 of 33

14 In addition to the active ingredient, triamcinolone acetonide, each metered spray also contains benzalkonium chloride, dextrose monohydrate, edetate disodium dihydrate, hydrochloric acid, microcrystalline cellulose and carboxymethylcellulose sodium, polysorbate 80 and purified water (hydrochloric acid or sodium hydroxide may be added to adjust the ph to between 4.9 and 5.1). Dosage forms and packaging NASAL SPRAY ALLERGY 24HR / APO-TRIAMCINOLONE AQ is supplied as a nonchlorofluorocarbon (CFC) containing-metered dose pump spray which will provide 120 actuations. It is supplied with a nasal adapter and patient instructions. Each bottle contains mg triamcinolone acetonide. Each actuation releases approximately 55 mcg triamcinolone acetonide from the nasal actuator to the patient. There are at least 120 actuations in one NASAL SPRAY ALLERGY 24HR / APO-TRIAMCINOLONE AQ bottle. After 120 actuations or 2 months after starting treatment, the amount delivered per actuation may not be consistent and the unit should be discarded. In the NASAL SPRAY ALLERGY 24HR / APO- TRIAMCINOLONE AQ Part III: CONSUMER INFORMATION, patients are provided with a checkoff form to track usage. Page 14 of 33

15 PART II: SCIENTIFIC INFORMATION PHARMACEUTICAL INFORMATION Drug Substance Proper Name: Triamcinolone Acetonide USP Chemical Name: 1) 9-Fluoro-11β, 16α, 17,21-tetrahydroxypregna-1,4-diene-3,20-dione cyclic 16,17-acetal with acetone 2) 9-Fluoro-11β, 21-dihydroxy-16α, 17-1-methylethylidenedioxy) pregna-1,4- diene-3,20-dione 3) Pregna-1,4-diene-3,20-dione, 9-fluoro-11,21-dihydroxy-16,17-[(1- methylethylidene)bis (oxy)]-, (11β,16α) Molecular formula and molecular weight: C 24 H 31 FO 6 ; g/mol Structural Formula: Physicochemical properties: Physical description: Solubility: Melting range/point: White to almost white microcrystalline powder. Practically insoluble in water, sparingly soluble in methanol, ethanol and chloroform, very slightly soluble in ether. Melts between 285 C and 295 C with decomposition. Page 15 of 33

16 CLINICAL TRIALS Comparative Bioavailability Studies A randomized, single dose, 2-way crossover comparative bioavailability study, conducted under fasting conditions, was performed on healthy male and female volunteers (21 males and 8 females). The rate and extent of absorption of triamcinolone acetonide was measured and compared following a 220 mcg dose (4 x 55 mcg/actuation, 2 sprays into each nostril) of Nasacort AQ (triamcinolone acetonide) Nasal Spray (sanofi-aventis, USA) and NASAL SPRAY ALLERGY / 24HR APO-TRIAMCINOLONE AQ Nasal Spray (Apotex Inc.) in 29 volunteers. The results from measured data are summarized in the following table: Parameter Summary Table of the Comparative Bioavailability Data Triamcinolone Acetonide 220 mcg (4 x 55 mcg/actuation, 2 sprays into each nostril) From Measured Data / Fasting Conditions Geometric Mean Arithmetic Mean (CV%) NASAL SPRAY ALLERGY 24HR / APO TRIAMCINOLONE AQ Nasal Spray (Apotex Inc.) (Canada) Nasacort AQ Nasal Spray (sanofi-aventis) (USA) Ratio of Geometric Means (%) 90% Confidence Interval (%) AUC 0-t (ng h/ml) (33.36) (34.82) AUC 0-inf (ng h/ml) (34.52) (36.13) C max (ng/ml) (33.76) (30.87) T max (h) 0.66 (72.84) 0.64 (66.78) T half (h) 2.96 (30.65) 2.94 (43.37) For the AUC 0-inf and T half parameters, N=28 for NASAL SPRAY ALLERGY 24HR / Apo-Triamcinolone AQ Nasal Spray and N=29 for Nasacort AQ Nasal Spray. Expressed as arithmetic mean (CV%) only. Nasacort AQ Nasal Spray is manufactured for sanofi-aventis and was purchased in the USA. Comparative Bioequivalency Studies A clinical efficacy study was conducted between March and October 2008 to demonstrate efficacy and bioequivalence. The study consisted of a double blind, multi-center, placebo controlled, parallel group, randomized clinical study. Of the 637 subjects (male and female) who completed the placebo run-in period and were randomized to one of the three treatments (NASAL SPRAY ALLERGY 24HR / APO-TRIAMCINOLONE AQ, Nasacort, and placebo), 511 subjects met the criteria for clinical equivalency analysis and 636 subjects were eligible for the clinical efficacy analysis. Each eligible subject received a dose of 220 mcg per day (55 mcg per actuation, 2 Page 16 of 33

17 actuations in each nostril once daily) for 14 days. Drug concentration/time profiles and pharmacokinetic parameters were not determined in this study. The primary efficacy and equivalence measures were based on the average morning and evening reflective total nasal symptom scores (TNSS) of rhinorrhea, nasal congestion, nasal itchiness and sneezing. The primary endpoint was the change in Reflective TNSS from baseline to the average of the data from the 14 days of treatment. A secondary efficacy analysis on the ITT and the PP populations was conducted in an identical manner to the primary efficacy analysis, except using the secondary efficacy measure of instantaneous TNSS (morning and evening instantaneous scores on runny nose, nasal congestion, nasal itchiness, and sneezing). The efficacy and bioequivalence results for the seasonal allergic rhinitis study are shown in the table below: Mean ± SD changes in reflective total nasal symptom scores (rtnss) and instantaneous total nasal symptom score (itnss) in seasonal allergic rhinitis trial Measures Statistics Superiority Assessment 1 (Triamcinolone acetonide 55 mcg/spray; 2 sprays per nostril daily) Test # Reference Placebo Ratio (Test/Ref) of Means (%) N (N=260) (N=249) (N=127) Equivalence Assessment 2 90% Confidence Interval rtnss Mean ± SD 1.8 ± ± ± P-value NA (vs. placebo) itnss Mean ± SD 1.7 ± ± ± P-value (vs. placebo) NA # NASAL SPRAY ALLERGY 24HR / APO-TRIAMCINOLONE AQ 55 mcg/metered nasal spray (Apotex Inc.) Nasacort AQ Nasal Spray (Sanofi-Aventis Pharmaceutical Products, Inc., USA) was purchased in the USA 1 Based on the Intent-To-Treat population 2 Based on the Per-Protocol population The safety and efficacy of triamcinolone acetonide aqueous nasal spray has been evaluated in 10 double-blind, placebo-controlled clinical trials in adults and children 12 years and older with seasonal or perennial allergic rhinitis. The number of patients treated with triamcinolone acetonide aqueous nasal spray in these studies was 1204; of these patients, 668 were males and 536 were females. Overall, in double-blind clinical trials of two to four weeks duration, analysis of the clinical studies has demonstrated that triamcinolone acetonide aqueous nasal spray 220 mcg once daily (2 sprays in each nostril) when compared to placebo provides statistically significant relief of nasal symptoms including sneezing, stuffiness, discharge, and itching. Page 17 of 33

18 The safety and efficacy of triamcinolone acetonide aqueous nasal spray, at doses of 110 mcg or 220 mcg once daily, has also been studied in two double blind placebo controlled trials of two and twelve weeks duration in children ages 4 through 12 years with seasonal and perennial allergic rhinitis. These trials included 355 males and 183 females. Triamcinolone acetonide aqueous nasal spray administered at either dose resulted in statistically significant reductions of allergic rhinitis symptoms. DETAILED PHARMACOLOGY Pharmacokinetics studies with radiolabelled triamcinolone acetonide have been carried out by the oral, pulmonary, and intravenous routes in several species. The pharmacokinetic behaviour of the triamcinolone acetonide was similar in all species within each route of administration. The results of studies in which triamcinolone acetonide was administered as an aerosol showed rapid disappearance of radioactivity from lungs, comparable to that observed following oral administration. Peak blood levels occurred in one to two hours. Virtually no radioactivity was present in the lungs and trachea 24 hours after dosing. Three major metabolites of triamcinolone acetonide have been identified. They are 6-hydroxy-triamcinolone acetonide (much less biologically active than triamcinolone acetonide), 21-carboxytriamcinolone acetonide and 21-carboxy-6-hydroxytriamcinolone acetonide. The latter two metabolites would also be expected to be substantially less active than the parent compound due to: a) the dependence of anti-inflammatory activity on the presence of the 21-hydroxyl group, b) the decreased activity observed upon 6-hydroxylation, and c) the markedly increased water solubility that favours rapid elimination. There appeared to be some qualitative differences in the metabolites among the species. No differences were detected in the metabolic pattern as a function of route of administration. Excretion: Studies completed utilizing radiolabelled triamcinolone acetonide given via oral and intravenous routes in several species show the major portion of the drug is eliminated in the feces, irrespective of the route of administration, with only one species (rabbit) showing significant urinary excretion of radioactivity. Glucocorticoid Effects: Triamcinolone acetonide is a potent derivative of triamcinolone. Although triamcinolone itself is approximately 1-2 times as potent as prednisone in animal models of inflammation, triamcinolone acetonide is much more potent. In cotton oil-induced ear inflammation, triamcinolone acetonide topically applied was 59 times more active than hydrocortisone when given by mouth in equivalent doses. Comparable effects were obtained in rats with cotton and asbestos pellet induced granuloma. Thymolytic potency was essentially equivalent, when given by the subcutaneous, intramuscular, intravenous and intraperitoneal routes. It was, however, 3-4 times more potent when given orally. Neither triamcinolone nor triamcinolone acetonide produced sodium retention in adrenalectomized rats or androgenic effects in castrated rats. Page 18 of 33

19 Human Pharmacology: The precise mechanism of action of the intranasal drug is unknown. However, clinical studies utilizing nasal administration have demonstrated effective local steroid activity with no evidence of systemic effects. Smears of the nasal mucosa obtained during clinical studies demonstrated marked reductions in nasal eosinophils, which are known to release highly active chemical mediators. TOXICOLOGY Animal: Acute toxicity studies in mice and rats and subacute toxicity studies in rats, rabbits and dogs were done by conventional routes of administration. The findings in these studies were typically those seen following the administration of potent glucocorticosteroids. Subacute toxicity studies in rats and dogs and chronic studies in rats and monkeys were conducted by inhalation of aerosolized triamcinolone acetonide. A one-month intranasal toxicity study in dogs with triamcinolone acetonide aqueous nasal formulation revealed no toxicity other than that expected from triamcinolone acetonide. The findings in these studies generally were minimal and the same as in studies carried out by conventional routes of administration, with changes typical of those seen with potent glucocorticoids. There were no gross histopathological or ultrastructural findings suggestive of untoward effects on the respiratory tract. An eye irritation study conducted in rabbits with triamcinolone acetonide aqueous nasal formulation revealed only a slight reversible irritation of the conjunctiva and iris. Teratogenic Tests: Teratology studies have been conducted in rats and rabbits by the subcutaneous route and by aerosol inhalation. The known teratogenic effects of glucocorticoids were found to occur following both routes of administration. Triamcinolone acetonide has been shown to be teratogenic in rats and rabbits. Teratogenic effects in both species at 0.02, 0.04 and 0.08 mg/kg/day (approximately 135, 270 and 540 mcg/m 2 /day in the rat and 320, 640 and 1280 mcg/m 2 /day in the rabbit, as calculated on a surface area basis), included low incidence of cleft palate and/or internal hydrocephaly and axial skeletal defects. Teratogenic effects, including CNS and cranial malformation have also been observed in non-human primates at 0.5 mg/kg/day (approximately 6.7 mg/m 2 /day). The doses of 0.02, 0.04, 0.08 and 0.5 mg/kg/day used in these toxicology studies are approximately 12.8, 25.5, 51 and times the minimum recommended dose of 110 mcg of triamcinolone acetonide aqueous nasal spray per day and 6.4, 12.7, 25.5 and times the maximum recommended dose of 220 mcg of triamcinolone acetonide aqueous nasal spray per day based on a patient body weight of 70 kg. Administration by aerosol inhalation to pregnant rats and rabbits produced embryotoxic and fetotoxic effects which were comparable to those produced by administration by other routes. Carcinogenesis, Mutagenesis: A recent literature report of a chronic bioassay conducted with several corticosteroids (budenoside, prednisolone, triamcinolone acetonide) indicated that all caused slightly increased incidence of liver tumors at toxic doses over a two-year study period. However, no evidence of treatment-related carcinogenicity was demonstrated after two years of once daily oral administration of triamcinolone acetonide at a maximum daily dose of 1.0 mcg/kg/day (6.1 mcg/m 2 /day) in male or female rats and 3.0 mcg/kg/day (12.9 mcg/m 2 /day) in male or female Page 19 of 33

20 mice. Impairment of Fertility: Male and female rats which were administered oral triamcinolone acetonide at doses as high as 15 mcg/kg/day (110 mcg/m 2 /day, as calculated on a surface area basis) exhibited no evidence of impaired fertility. The maximum human dose, for comparison, is 6.3 mcg/kg/day (240 mcg/m 2 /day). However, a few female rats which received maternally toxic doses of 8 or 15 mcg/kg/day (60 mcg/m 2 /day or 110 mcg/m 2 /day, respectively, as calculated on a surface area basis) exhibited dystocia and prolonged delivery. Developmental toxicity, which included increases in fetal resorptions and stillbirths and decreases in pup body weight and survival, also occurred at the maternally toxic doses ( mcg/kg/day or mcg/m 2 /day, as calculated on a surface area basis). Reproductive performance of female rats and effects on fetuses and offspring were comparable between groups that received placebo and nontoxic or marginally toxic doses (0.5 and 1.0 mcg/kg/day or 3.8 mcg/m 2 /day and 7.0 mcg/m 2 /day). Page 20 of 33

21 REFERENCES 1) Blauert-Cousounis SP, Ziemniak JA, McMahon SC, Grebow PE. The pharmacokinetics of triamcinolone acetonide after intranasal, oral inhalation and intramuscular administration. J Allergy Clin Immunol 1989; 83 (1):221 2) Garbe E, Lelorier J, Boivin JF, Suissa S. Inhaled and nasal glucocorticoids and the risks of ocular hypertension or open-angle glaucoma. JAMA 1997; 227: ) Siegal SC. Topical intranasal corticosteroid therapy in rhinitis. J Allergy Clin Immunol 1988; 81 (5): Pt.2: ) Spector SL, WHR-5029 (Triamcinolone acetonide nasal aerosol) versus placebo in perennial allergic rhinitis. Ann Allergy 1987; 58(4):296 5) Storms WW, Bodman SF, Nathan RA, Gawchick SM, Rooklin AK, Gorder JW, Huber FJ. WHR-5049 (Triamcinolone acetonide nasal aerosol) in the treatments of seasonal ragweed allergic rhinitis (SRAR). Ann Allergy 1988;60(2):166 6) Tinkelman D, Falliers C, Gross G, Segal A, Southern L,Welch M et al. Multicenter evaluation of triamcinolone acetonide nasal aerosol in the treatment of adult patients with seasonal allergic rhinitis. Ann Allergy 1990;64 (Part II): ) Weakley S, Pinkett O, Woehler T. An evaluation of WHR-5029 (triamcinolone acetonide) in patients with allergic rhinitis. J Allergy Clin Immunol 1987; 79(1)L 206 8) Webb R, Golden D, Goldstein S, Shapiro G, Wray B, Gorder J. Triamcinolone acetonide nasal aerosol-whr-5029 (TA) for seasonal allergic rhinitis. J Allergy Clin Immunol 1988; 81(1):173 9) Welch Mj, Meltzer Eo, Orgel Ha, Kemp Jp, Gorder Jw, Garcia JD. Treatment of seasonal allergic rhinitis (SAR) with triamcinolone acetonide (TA) nasal aerosol. Ann Allergy 1988; 60(2):166 10) Product Monograph - NASACORT Allergy 24HR / NASACORT AQ (Triamcinolone Acetonide Spray) Aqueous Nasal Spray 55 mcg/ Metered Spray. sanofi-aventis Canada Inc. Date of Revision: December 2, 2013 Page 21 of 33

22 IMPORTANT: PLEASE READ PART III: CONSUMER INFORMATION NASAL SPRAY ALLERGY 24HR Adults and Children 12 Years and Older Triamcinolone Acetonide Aqueous Nasal Spray 55 mcg/metered Spray Apotex Standard This leaflet is part III of a three-part Product Monograph published when NASAL SPRAY ALLERGY 24HR was approved for sale in Canada and is designed specifically for Consumers. This leaflet is a summary and will not tell you everything about NASAL SPRAY ALLERGY 24HR. Contact your doctor or pharmacist if you have any questions about the drug. ABOUT THIS MEDICATION The Name of Your Medicine: The name of your medicine is NASAL SPRAY ALLERGY 24HR. This belongs to a group of medicines called corticosteroids. What the medication is used for: NASAL SPRAY ALLERGY 24HR is indicated in adults and children 12 years of age and older for the temporary relief of multi-symptoms of perennial and seasonal allergic rhinitis such as: nasal congestion runny nose sneezing itchy nose What it does: NASAL SPRAY ALLERGY 24HR reduces the irritation and inflammation in the lining of the nose and nasal passages and so it relieves the blocked up feeling in the nose, the runny nose, itching and sneezing. It helps some people within the first day of treatment; however, for other people, it may take 3 to 4 days to feel a relief. When it should not be used: If you are allergic to triamcinolone acetonide or any of the ingredients of NASAL SPRAY ALLERGY 24HR If you have active or dormant tuberculosis, or untreated fungal, bacterial and viral infection. What the medicinal ingredient is: The active ingredient in NASAL SPRAY ALLERGY 24HR is triamcinolone acetonide. What the nonmedicinal ingredients are: Benzalkonium chloride, dextrose monohydrate, edetate disodium dihydrate, hydrochloric acid, microcrystalline cellulose and carboxymethylcellulose sodium, polysorbate 80 and purified water. Sodium hydroxide may be added to adjust ph. What dosage forms it comes in: NASAL SPRAY ALLERGY 24HR is a nonchlorofluorocarbon (non-cfc) containing-metered dose pump spray which will provide 120 actuations. Each actuation releases approximately 55 mcg triamcinolone acetonide through the nasal actuator. WARNINGS AND PRECAUTIONS BEFORE you use NASAL SPRAY ALLERGY 24HR, talk to your doctor or pharmacist if you: are using an asthma medicine or prescription steroid medicine; are taking any other prescription or nonprescription (over-the-counter) medicines; have already taken NASAL SPRAY ALLERGY 24HR or any other corticosteroids and developed an allergy or intolerance to any of them; are allergic to any other substances, such as food, preservatives or dyes; have had recent nasal ulcers, nasal surgery or nasal injury that have not healed; have recently had nasal infection with Candida albicans (a fungal infection); currently have an eye infection; have or had glaucoma (elevated pressure inside the eye ball) or cataracts (clouding of the lens of the eye). Slower rate of growth has been reported in some children receiving treatment. You and your doctor should monitor your child s growth. Nasal and inhaled corticosteroids use may result in the development of glaucoma and/or cataracts. Page 22 of 33

23 IMPORTANT: PLEASE READ Pregnancy and breast-feeding If you are pregnant or breast-feeding, you should not use this medicine unless your doctor has advised you that the benefits of using it are higher than the possible risk to your baby. Stop use and ask a doctor or pharmacist if: you have an allergic reaction, such as a rash, problems swallowing or breathing, swelling of your lips, face or tongue. Seek medical help right away; you have, or come into contact with someone who has chickenpox, measles or tuberculosis; you have, or develop symptoms of an infection such as a persistent fever; you have any change in vision; you have severe or frequent nosebleeds. PROPER USE OF THIS MEDICATION This medicine is only intended for use by inhalation through the nose and should not be taken by mouth. Follow the INSTRUCTIONS FOR USE described below. If you have any problems, tell your doctor or pharmacist. Usual dose: Adults and children 12 years of age and older: once daily, spray 2 times into each nostril, while sniffing gently; once allergy symptoms improve, you may reduce to 1 spray in each nostril per day. When using this product: In some people, symptom improvement can start within the first day of treatment; however, for other people, it may take 3 to 4 days to feel a relief. It may take up to one week for 24-hour relief; that is why it is important that you use it daily. Follow a regular dosing schedule. If your symptoms have not improved after one week of treatment with NASAL SPRAY ALLERGY 24HR, see your doctor. Do not use more than directed. Do not share this bottle with anyone else as this may spread germs. Do not use continuously for more than six months without consulting your doctor. Overdose: If you think you have taken too much NASAL SPRAY ALLERGY 24HR or accidentally ingested it orally, contact your healthcare professional, hospital emergency department or regional Poison Control Centre immediately, even if there are no symptoms. Missed Dose: If you miss a dose, do not worry; take a dose if you remember within an hour or so. However, if you do not remember until later, skip the missed dose and go back to your regular dosing schedule. Do not use a double dose to make up for a forgotten dose. SIDE EFFECTS AND WHAT TO DO ABOUT THEM Along with its needed effects, a medicine may cause some unwanted effects. Contact your physician as soon as possible if any of the following occur: if you notice that any discharge from your nose is yellow or green; which may be a nasal infection; if you have heartburn or indigestion; if you experience an unpleasant taste or smell; if your nose or throat becomes painful or if you have a severe nose bleed after using the nasal spray; if you have flu syndrome (fever, muscle pain, weakness and/or fatigue); if you have inflammation/irritation of the airways, cough, shortness of breath; if you feel unwell, sick (nausea), dizzy or tired, have sleeping problems or have any other problems. Other side effects may occur that usually do not need medical attention. They may go away as your body adjusts to the medicine. However, check with your doctor if any of the following side effects continue or are bothersome: Sneezing; Headaches; Burning, dryness or other irritation inside the nose (lasting only a short time after applying the medication). In rare instances, NASAL SPRAY ALLERGY 24HR can cause damage to the middle part of the inside of the nose (called nasal septum ). Discuss any worries you may have about this with your doctor Page 23 of 33

24 IMPORTANT: PLEASE READ or pharmacist. NASAL SPRAY ALLERGY 24HR may have an effect on how fast children grow. If your child is taking NASAL SPRAY ALLERGY 24HR your healthcare provider will need to regularly check the height of your child and adjust the dose as appropriate. Other side effects not listed above may also occur in some patients. If you notice any side effects not listed in this leaflet, please tell your doctor or pharmacist. Reporting Side Effects You can help improve the safe use of heath products for Canadians by reporting serious and unexpected side effects to Health Canada. Your report may help to identify new side effects and change the product safety information. 3 ways to report: Online at MedEffect ( By calling (toll free); By completing a Consumer Side Effect Reporting Form and sending it by: - Fax to (toll free), or - Mail to: Canada Vigilance Program Health Canada, Postal Locator 0701E Ottawa, ON K1A 0K9 Postage paid labels and the Consumer Side Effect Reporting Form are available at MedEffect ( NOTE: Contact your health professional if you need information about how to manage your side effects. The Canada Vigilance Program does not provide medical advice. Store at room temperature 15 C - 30 C. Do not use NASAL SPRAY ALLERGY 24HR after the expiry date which is stated on the carton and the bottle after EXP. After 120 actuations or 2 months after starting treatment, the amount delivered per spray may not be consistent and the bottle should be discarded. APPENDIX: INSTRUCTIONS FOR USE Please see Instructions for Use included. MORE INFORMATION REMEMBER this medicine is for YOU. Never give it to others. It may harm them even if their symptoms are the same as yours. After 120 actuations or 2 months after starting treatment, the amount delivered per spray may not be consistent and the bottle should be discarded. Keep all medicines out of the sight and reach of children. If you have questions or are not sure about anything, then you should ask your doctor or pharmacist. You may want to read this leaflet again. Please DO NOT THROW IT AWAY until you have finished your medicine. This leaflet plus the full product monograph, prepared for health professionals, can be obtained by contacting DISpedia, Apotex's Drug Information Service at: This leaflet can also be found at: This leaflet was prepared by Apotex Inc., Toronto, Ontario, M9L 1T9. Last revised: January 25, 2016 HOW TO STORE IT Keep out of the sight and reach of children. Page 24 of 33

25 IMPORTANT: PLEASE READ INSTRUCTIONS FOR USE It is important to shake the bottle gently before each use. Also, after 120 sprays or 2 months after starting treatment, the amount delivered per spray may not be consistent and the bottle should be discarded. Do not transfer any remaining suspension to another bottle. 1. IMPORTANT INFORMATION a. Read this insert for complete instructions on how to get a bottle ready (primed), how to use the spray bottle and how to clean the spray nozzle. b. Keep this insert as it contains important information. c. NASAL SPRAY ALLERGY 24HR is for nasal use only. d. Do not use more than directed. e. Do not share this bottle with anyone else as this may spread germs. 2. STEPS TO GET A NEW BOTTLE READY FOR USE (PRIMED) A. Before first use, a new bottle must be primed. a. Remove cover and clip (Figure A). b. Shake the bottle gently before use. c. Hold the bottle upright. Point the spray away from you while doing this. Press and release actuator until a fine mist is produced, taking care not to spray into eyes or face (as shown in Figure B). If you get the spray in your eyes, rinse well with water. d. The spray is now ready to use. Figure A B. If NASAL SPRAY ALLERGY 24HR has not been used for more than 2 weeks, prime bottle again. Repeat steps a through c above 3 USE INSTRUCTIONS a. Blow nose gently to clear nostrils. b. Remove cover and clip, then shake the bottle gently. c. Hold the bottle with thumb under bottle and spray nozzle between your fingers (as shown in Figure B). d. Close off one nostril with your finger. Figure B e. Aim nozzle toward back of nose (Figure C). DO NOT spray toward nasal septum (the wall between the 2 nostrils) (Figure D). Figure C Figure D f. While sniffing gently, spray. Correct Position Wrong Position For complete dosing instructions, see section above PROPER USE OF THIS MEDICATION. g. Repeat steps d through f for the other nostril. h. After using the nasal spray, wipe nozzle with a tissue and replace cap. Page 25 of 33

26 IMPORTANT: PLEASE READ NOTE: Avoid blowing nose for 15 minutes after use. If nozzle does not spray properly, see cleaning instructions below. 4. IF PUMP DOES NOT SPRAY PROPERLY, THE NOZZLE MAY BE BLOCKED Figure E a. Never try to unblock nozzle or enlarge the tiny spray hole with a pin or other sharp objects. This is because it can stop the spray from working. (Figure E). b. Clean the nozzle as shown below. 5. CLEANING INSTRUCTIONS a. Remove the cover. b. Gently pull off the spray nozzle away from bottle (Figure F). Figure F c. Rinse SPRAY NOZZLE ONLY under warm water (Figure G). d. Shake or tap to remove any water that is left. e. Re-attach spray nozzle to bottle. f. Press and release spray nozzle until a fine spray is produced, taking care not to spray in your eyes or face. If you get the spray in your eyes, rinse well with water. g. Replace the cover over the nozzle. Figure G NASAL SPRAY ALLERGY 24HR is now ready to use We have included a convenient check-off chart to assist you in keeping track of medication sprays used. This will help assure that you receive the 120 "full sprays" of medication present. Please note that the bottle has been filled with extra solution to accommodate the initial priming activity. Please also note that any additional repriming (i.e. other than initial priming) should be accounted for as a full spray. Page 26 of 33

27 IMPORTANT: PLEASE READ NASAL SPRAY ALLERGY 24HR Spray Check-Off (include treatment inhalations and repriming sprays) Check off one square for one spray. After 120 sprays or 2 months after starting treatment, the amount delivered per spray may not be consistent and the bottle should be discarded. Do not transfer any remaining suspension to another bottle Page 27 of 33

28 IMPORTANT: PLEASE READ PART III: CONSUMER INFORMATION APO-TRIAMCINOLONE AQ Children 4 to 12 years Triamcinolone Acetonide Aqueous Nasal Spray 55 mcg/metered Spray Apotex Standard This leaflet is part III of a three-part Product Monograph published when APO- TRIAMCINOLONE AQ was approved for sale in Canada and is designed specifically for Consumers. This leaflet is a summary and will not tell you everything about APO- TRIAMCINOLONE AQ. Contact your doctor or pharmacist if you and your child have any questions about the drug. ABOUT THIS MEDICATION The Name of Your Medicine: The name of your medicine is APO- TRIAMCINOLONE AQ (triamcinolone acetonide aqueous nasal spray). This is one of a group of medicines called corticosteroids. APO- TRIAMCINOLONE AQ can only be obtained on the prescription of a doctor. What the medicinal ingredient is: The active ingredient in APO-TRIAMCINOLONE AQ is triamcinolone acetonide. What the nonmedicinal ingredients are: Benzalkonium chloride, dextrose monohydrate, edetate disodium dihydrate, hydrochloric acid, microcrystalline cellulose and carboxymethylcellulose sodium, polysorbate 80 and purified water. Sodium hydroxide may be added to adjust ph. What dosage forms it comes in: APO-TRIAMCINOLONE AQ is a nonchlorofluorocarbon (non-cfc) containingmetered dose pump spray which will provide 120 actuations. Each actuation releases approximately 55 mcg triamcinolone acetonide through the nasal actuator. WARNINGS AND PRECAUTIONS Before you use APO-TRIAMCINOLONE AQ talk to your doctor or pharmacist if: If your child has already taken APO- TRIAMCINOLONE AQ or any other corticosteroids and developed an allergy or intolerance to any of them; If your child is allergic to any other substances, such as food, preservatives or dyes; What the medication is used for: APO-TRIAMCINOLONE AQ is used to treat seasonal allergic rhinitis (including hayfever) and perennial rhinitis (year-round inflammation of the mucous membrane of the nose). Symptoms of these conditions include itching, blocked up feeling in the nose and excessive sneezing. What it does: APO-TRIAMCINOLONE AQ reduces the irritation and inflammation in the lining of the nose and nasal passages and so it relieves the blocked up feeling in the nose, the runny nose, itching and sneezing. If you are pregnant or breast feeding, or likely to become pregnant or breast feed. Your doctor may decide not to prescribe this medication in these circumstances; If your child is taking any other prescription or nonprescription (over-the-counter) medicines; If your child suffers from any other medical problems or if your child has had a recent injury, surgery to their nose, or nasal infection with Candida albicans (a fungal infection). When it should not be used: Allergic reaction to any of the ingredients of APO-TRIAMCINOLONE AQ (triamcinolone acetonide aqueous nasal spray) (See What the nonmedicinal ingredients are) and in patients with active or dormant tuberculosis, or untreated fungal, bacterial and viral infection. Glaucoma (increase in eye pressure that cause visual problem) or cataracts (clouding of the lens of the eye) have been reported in patients receiving nasal corticosteroids. If you notice any visual problems, talk to your doctor. Page 28 of 33

29 IMPORTANT: PLEASE READ Slower rate of growth has been reported in some children receiving treatment. You and your doctor should monitor your child s growth. In case of pregnancy or breastfeeding, contact your doctor or healthcare provider. PROPER USE OF THIS MEDICATION Usual dose: Follow the INSTRUCTIONS FOR USE described below. If you have any problems tell your doctor or pharmacist. It is important that your child inhales each dose through the nose as instructed. The label will usually tell you and your child how many doses to take. If it does not, ask your doctor or pharmacist; DO NOT inhale more doses or use the nasal spray more often than your doctor advises. It takes a few days for this medicine to work. IT IS VERY IMPORTANT THAT YOU USE IT REGULARLY. DO NOT STOP treatment even if your child feels better, unless told to do so by your doctor. schedule. Do not double doses. What to do if you stop your medicine: If your doctor decides to stop your child s treatment, do not keep any leftover medicine unless your doctor tells you to. SIDE EFFECTS AND WHAT TO DO ABOUT THEM Along with its needed effects, a medicine may cause some unwanted effects. Contact your doctor as soon as possible if any of the following occur: If you and your child notice that any discharge from your nose is yellow or green; which may be a nasal infection. If your child experiences an unpleasant taste or smell; If your child s nose or throat becomes painful or if your child has a severe nose bleed after using the nasal spray; If your child feels unwell or has any other problems; If your child s symptoms have not improved after three weeks of treatment with APO- TRIAMCINOLONE AQ, tell your doctor. Children 4 to 12 years of age: The recommended dose is 110 mcg per day given as one spray in each nostril once a day. Other side effects may occur that usually do not need medical attention. They may go away as your child s body adjusts to the medicine. However, check with your doctor if any of the following side effects continue or are bothersome: Sneezing; APO-TRIAMCINOLONE AQ is not recommended for children under 4 years of age. Overdose: Headaches; Burning, dryness or other irritation inside the nose (lasting only a short time after applying the medication) If you and your child think they have taken too much APO-TRIAMCINOLONE AQ or accidentally ingested it orally, contact your healthcare professional, hospital emergency department or regional Poison Control Centre immediately, even if there are no symptoms. Missed Dose: If your child misses a dose, do not worry; take a dose if you and your child remember within an hour or so. However, if you and your child do not remember until later, skip the missed dose and go back to your child s regular dosing APO-TRIAMCINOLONE AQ may have an effect on how fast children grow. If your child is taking APO-TRIAMCINOLONE AQ, your healthcare provider will need to regularly check the height of your child and adjust the dose as appropriate. Other side effects not listed above may also occur in some patients. If you and your child notice any other effects, check with your doctor. Page 29 of 33

30 IMPORTANT: PLEASE READ Reporting Side Effects You can help improve the safe use of heath products for Canadians by reporting serious and unexpected side effects to Health Canada. Your report may help to identify new side effects and change the product safety information. 3 ways to report: By calling (toll free); By completing a Consumer Side Effect Reporting Form and sending it by: Fax to (toll free), or Mail to: Canada Vigilance Program Health Canada, Postal Locator 0701E Ottawa, ON K1A 0K9 Online at MedEffect ( Postage paid labels and the Consumer Side Effect Reporting Form are available at MedEffect ( NOTE: Contact your health professional if you need information about how to manage your side effects. The Canada Vigilance Program does not provide medical advice. HOW TO STORE IT Keep out of the sight and reach of children. Store at room temperature 15 C - 30 C. After 120 actuations or 2 months after starting treatment, the amount delivered per spray may not be consistent and the bottle should be discarded. APPENDIX: INSTRUCTIONS FOR USE Please see Instructions for Use included. MORE INFORMATION REMEMBER this medicine is for YOUR CHILD. Only a doctor can prescribe it for your child. Never give it to others. It may harm them even if their symptoms are the same as yours. After 120 actuations or 2 months after starting treatment, the amount delivered per spray may not be consistent and the bottle should be discarded. Keep all medicines out of the sight and reach of children. If you have questions or are not sure about anything, then you should ask your doctor or pharmacist. You may want to read this leaflet again. Please DO NOT THROW IT AWAY until you have finished your medicine. This leaflet plus the full product monograph, prepared for health professionals, can be obtained by contacting DISpedia, Apotex's Drug Information Service at: This leaflet can also be found at: This leaflet was prepared by Apotex Inc., Toronto, Ontario, M9L 1T9. Last revised: January 29, 2016 Page 30 of 33

31 IMPORTANT: PLEASE READ Instructions for Use It is important to shake the bottle gently before each use. Also, after 120 sprays or two months after starting treatment, the amount delivered per spray may not be consistent and the bottle should be discarded. Do not transfer any remaining suspension to another bottle. Before each use of your APO-TRIAMCINOLONE AQ nasal spray, ask your child to gently blow their nose, making sure your child s nostrils are clear. Then follow these steps: PRIOR TO USE 1) Pull the cover and the clip off the spray pump unit. Do not attempt to enlarge the tiny hole in the spray tip. If the actuator has come off the pump stem, re-insert stem in actuator. 2) Shake the spray pump unit. PREPARING FOR USE 3) To prepare for use, the spray pump unit must be primed prior to the first use. To prime, put two fingers on the shoulders of the bottle. Push bottle with thumb FIRMLY and QUICKLY for a full-stroke actuation until a fine mist appears (5 pumps). Hold the nozzle pointing away from you while you are doing this. Now your spray pump unit is primed and ready for use. 4) A fine mist can only be produced by a rapid and firm pumping action. TO USE 5) Repriming is only necessary when the spray pump unit has not been used for more than 14 days. To reprime, shake the bottle and pump only once. Now the spray pump unit is reprimed. 6) Gently blow nose to clean nostrils, if needed. 7) Pull the cover and the clip off the spray pump unit, and shake pump unit. Page 31 of 33

32 IMPORTANT: PLEASE READ 8) Hold spray pump unit firmly as shown with the index and middle finger on either side of the spray tip and thumb on bottom of the bottle. Rest back of index finger against upper lip. BE CAREFUL SO FINGERS WILL NOT SLIP OFF SPRAY PUMP UNIT AS YOU SPRAY. 9) Put the spray tip into one nostril (tip should not reach far into the nose). BEND HEAD FORWARD so spray will aim toward the back of the nose. 10) Point tip straight back into nose. Close the other nostril with finger. Pump spray unit by pushing the bottle with thumb FIRMLY and QUICKLY for a full-stroke actuation and sniff gently at the same time. Repeat procedure for the other nostril. 11) Repeat steps 8, 9, 10 if instructed to use more than one spray per nostril. 12) Avoid blowing nose for 15 minutes following dosing. 13) After using the spray: Wipe the nozzle carefully with a clean tissue or a handkerchief, and replace the dust-cap. Keep the cover and the clip on the spray pump unit when not in use. 14) If the spray does not work and it may be blocked, clean as follows. NEVER try to unblock it or enlarge the tiny spray hole with a pin or other sharp object because this will destroy the spray mechanism. The nasal spray should be cleaned at least once a week or more often if it gets blocked. 15) Cleaning Instructions 1. Remove the dust-cap and spray nozzle only (pull off). 2. Soak the spray nozzle and dust-cap in warm water for a few minutes, and then rinse under cold running tap water. 3. Shake or tap off excess water and allow to air-dry. 4. Re-fit the spray nozzle. 5. Prime the unit as necessary until a fine mist is produced and use as normal. We have included a convenient check-off chart to assist you in keeping track of medication sprays used. This will help assure that you receive the 120 "full sprays" of medication present. Please note that the bottle has been filled with extra solution to accommodate the initial priming activity. Please also note that any additional repriming (i.e. other than initial priming) should be accounted for as a full spray. Page 32 of 33